HomeMy WebLinkAboutEddy St. #53 - 8/7/1996,;.COMMONWEALTH OF ,MASSACHUSETTS'
\Lv Department of Labor & Industries and Department of Public Health
NOTIFICATION OF DELEADING WORK 11.
1 ... 1..
`All aeations.` 64, this form must be oompletud in'ordar'to"aomply '
tho.:notilipation:Faquiro nta oL:M.�:,11.;Iq:,11,7,:;5;19'j„••,+. .. r.:
'iL; .. �.a .�'.`,• ; 454, CI•IIi',22.00. ar♦c� ;30$, (M 460.000, a;. mat ,;aaent,,lYamo�cyad. , . .. ..
. .. FILE NUFD7ER: .. (AGENCY USE)
Contractor, peKonning:project' Lead Source/Dennis Ranson;.tucense#.D0000912
Exp.date 9/14/96
Lead :Paipt. Inspector Environmental Lead Detection License #
:xl ,•�^uc, , ,.f� 1 i I',: +,! Date Of In9iae On
If low rls t'deleaaing+!work is'being performed,' complete the following line:
Property ;owner Mansfield Housing Auth.Agent(s) Francene Bragga
;Address'•of'Project,
u'Tt,.... ,.�; 4:'nrp,Y ..7... r.;•r;, ,uJ,...�d. �il;4ii .. .. .. ': ,',�i:.,,
Bui' ia:nq eti (if any)��nsfie,ld Housing Auth. FlGor:•
AI + u 53 ka 'Street - A t , :No '
Stregg ddress �* P
0-1 A'Afl I'SLG.�`}})t7 t earn,; .. ua ,.. 1 : If�ll 14 '
,city•.
Mdnsi,�id,.,,MA zip ."6�04g..:
Dgleadiag;Method Wei/Dry Scraping Heat .Gun Cay'stics
Liquid'Encalpsulant' -,`. overing 'Demolitidn Replacement` Oth'er't-• 1i''
It„;sOther1! ; seleRted,.,!please ,explain
. , ...
Check one.,q;: dwe :l•1•lnq is,.Tulti-fainliy single,famtly XX
Start•date,'• 8/7/96 Completion date �/7/96
When -will
be„'dope• ..A.M 1Cx. P.M. - WeekendsR:0.
Project Supervisor; s, name Chri.stopher Roy License )) DS002126
Property Owner ' Mansfield Housing Authority,
Address 22 Bicentennial Court
City. Mansfield ' State MA Zip 02048
Telephone 508-339-6'890
In case, of•emergency;;contact Scott Knightly
Phone: day 603-74979274: 1 evening 603-8,68-2396
(over)
In accordance with Massachusetts, General LBWS c. 111 S 107 CMR. 22.00 anU-105 CMR'•460 000;notice
of the date and methods(sP-i.ot;•rrem9val'or covering of paint, plaster qIr, other accessiblA'maeecials
containing dangerous'1"evels°'•of"'lead'is' to be' provided and must+'be:recei•vod by the following
persons, at least 't•n'(10)+daye prior to beginning of doloadlhg.
(ia xn srii '-:.71'11i V1`.a:';t;ar.,;4, :..: ,.,..
1. Occupants of the dwol,ligg _unit
2. All other occupants,:,of,,Cheresidential promisor, if any'. .i,r. ,•:i ;, It;
3. Dirocto r, Childhoo`dv'Lo6di ng"Pol soiling Provention Program " i01'' `'•Fax (617) 753-0436
Depa rtment'of Public, Health; 470 Atlantic Avenue, Dolton, MA 02110
4. Director, Asbestos 4 Lead Program Fax (617) 727-7560
Department of Labor'4 Industries.
Room. 13006,YP10,Q4Ca ridge Street,. •; apijrY[;; I;[ii ;
'Boston;'MA 02202,�"^� -.
5;-'LOCarleoard of Health/Code Enforcement Agency '
6. Massachusetts HlstorScalCumtnissSon (If promises is -listed on the State Register
• 'Massachusetts lil,4d'.�,[p of Historic Places', this notification must be
"•'Doston;-:MA;'0212$!..'.' made upon receipt ;of an Orderto Correct
Violations or at 1•east. 30:daysprior to
initiating preyaqivg, deJ..eading)
'Fax (617) 727-5120
Deleading•Contractor... ....... _...«..:.,... .................
I' .)4q ll. :.
The .undersigned;;hereby,s,tates, under the pains and penalties-'-.of--perjury, that
heshe'lias'read"andpunderstood the Commonwealth of Masggchusetts Deleading,
Regulations,,, ,454�;CMR 22':00:":a4d'Leading' Poisoning Prevention and Control
i'Regulationst 105ACM,AA60.000;'��.and. that the information;' contained.,in, this
hot 3:1.fication 3 'true and:correct"t'o•the best of his and, belief.
Date 6/2'5796 Signed;
President .:
.. .. ... _... ..... _... ... .... ... ...... .. •,Company:
Lead Source;;,
$roperty°owner '(If`owher"'or'unlicensbd owner's agent will be performing -low -risk deleading work)
I certify'.`that I %-'a�ve, complied with the training requirements'' of the.
Commonwealth of.MassachusettsI.Lead Poising Prevention and Control Regulations,
105 CMR1.460 175,)i'iEor`rlowne5/,argent'low-risk abatement and containment. , I
'further�Tcertl.fy, that+I,:i'or my agent'will be performing -- .
the fol]owing,., rl eactivities;(I have circled all that apply):
...,..
applyi nq liquid.oncappul'ant ' capping baseboards
opp.1ying extprior,l vinyl -siding COVering surfaces
—•-•-•---romoving.;doors,;;lcabl.npt,, doors, shutters
1`oortl(y'thaC`aii-tho•,lnfoema,tlon contalnud in this notification is true and correct ern the
best of my' knowledge;nndf� bollof,
Date: 6/25/96 ^ai'.. st.i GignoUo _ ..